Neonatal lungs--can absolute lung resistivity be determined non-invasively?

Addition of internal electrodes is beneficial for focused bioimpedance measurements in the lung

OBJECTIVE

Bioimpedance measurements such as bioimpedance spectroscopy (BIS) or electrical impedance tomography (EIT) are used in many biomedical applications. While BIS measures and analyzes the impedance in a frequency range at constant electrode positions, EIT aims to reconstruct images of the conductivity distribution from multiple measurements at different electrode positions. Our aim is to add spatial information to tetrapolar BIS measurements by using electrode positions that focus measurements on desired regions of interest. In this paper, we aim to investigate, whether internal electrodes that can be integrated into breathing or gastroesophageal tubes, can improve the local sensitivity of bioimpedance spectroscopy measurements.

APPROACH

We present the results of a simulation study, in which we investigated more than 4 M different electrode configurations on their ability to monitor specific regions of interest (ROI) in the lung. Based on the sensitivity, which describes the impact of a conductivity change on the measured impedance, we define three main criteria which we use to evaluate our simulation results: the selectivity [Formula: see text], which describes the impact of a conductivity change inside the region of interest compared to a conductivity change outside the ROI; the homogeneity [Formula: see text], which describes the distribution of the sensitivity inside the ROI; and the absolute impedance contribution ratio [Formula: see text], which describes the contribution of the ROI to the measured impedance.

MAIN RESULTS

Depending on the region of interest, electrode configurations using internal electrodes are between 9.8 % and 90 % better with respect to these criteria than configurations using external electrodes only.

SIGNIFICANCE

The combination of internal and external electrodes improves the focusing ability of tetrapolar impedance measurements on specific lung regions, which may be especially beneficial for lung monitoring in intensive care.

Monitoring Lung Volumes During Mechanical Ventilation

Respiratory inductive plethysmography (RIP) is a non-invasive method of measuring change in lung volume which is well-established as a monitor of tidal ventilation and thus respiratory patterns in sleep medicine. As RIP is leak independent, can measure end-expiratory lung volume as well as tidal volume and is applicable to both the ventilated and spontaneously breathing patient, there has been a recent interest in its use as a bedside tool in the intensive care unit.

High-power CMOS current driver with accurate transconductance for electrical impedance tomography

Current drivers are fundamental circuits in bioimpedance measurements including electrical impedance tomography (EIT). In the case of EIT, the current driver is required to have a large output impedance to guarantee high current accuracy over a wide range of load impedance values. This paper presents an integrated current driver which meets these requirements and is capable of delivering large sinusoidal currents to the load. The current driver employs a differential architecture and negative feedback, the latter allowing the output current to be accurately set by the ratio of the input voltage to a resistor value. The circuit was fabricated in a 0.6- μm high-voltage CMOS process technology and its core occupies a silicon area of 0.64 mm (2) . It operates from a ± 9 V power supply and can deliver output currents up to 5 mA p-p. The accuracy of the maximum output current is within 0.41% up to 500 kHz, reducing to 0.47% at 1 MHz with a total harmonic distortion of 0.69%. The output impedance is 665 k Ω at 100 kHz and 372 k Ω at 500 kHz.

Continuous non-invasive monitoring of tidal volumes by measurement of tidal impedance in neonatal piglets

Background

Electrical Impedance measurements can be used to estimate the content of intra-thoracic air and thereby give information on pulmonary ventilation. Conventional Impedance measurements mainly indicate relative changes, but no information concerning air-volume is given. The study was performed to test whether a 3-point-calibration with known tidal volumes (VT) during conventional mechanical ventilation (CMV) allows subsequent calculation of VT from total Tidal-Impedance (tTI) measurements using Quadrant Impedance Measurement (QIM). In addition the distribution of TI in different regions of the thorax was examined.

Methodology and Principal Findings

QIM was performed in five neonatal piglets during volume-controlled CMV. tTI values at three different VT (4, 6, 8 ml/kg) were used to establish individual calibration curves. Subsequently, each animal was ventilated with different patterns of varying VT (2–10 ml/kg) at different PEEP levels (0, 3, 6, 9, 12 cmH₂O). VT variation was repeated after surfactant depletion by bronchoalveolar lavage. VT was calculated from tTI values (VT_calc) and compared to the VT delivered by the ventilator (VT_PNT). Bland-Altman analysis revealed good agreement between VT_calc and VT_PNT before (bias −0.08 ml; limits of agreement −1.18 to 1.02 ml at PEEP = 3 cmH₂O) and after surfactant depletion (bias −0.17 ml; limits of agreement −1.57 to 1.22 ml at PEEP = 3 cmH₂O). At higher PEEP levels VT_calc was lower than VT_PNT, when only one fixed calibration curve (at PEEP 3 cmH₂O) was used. With a new calibration curve at each PEEP level the method showed similar accuracy at each PEEP level. TI showed a homogeneous distribution over the four assessed quadrants with a shift toward caudal regions of the thorax with increasing VT.

Conclusion

Tidal Impedance values could be used for precise and accurate calculation of VT during CMV in this animal study, when calibrated at each PEEP level.

Heart and respiration rate changes in the neonate during electroencephalographic seizure

An investigation of changes in the neonatal electrocardiogram (ECG) and respiration signals from labelled seizure data for five neonatal patient records is reported. A decrease during seizure of 5.70% in the mean RR-interval was found. The mean respiration rate per epoch was found to decrease by a mean 18.44% during seizure. No significant change in the RR-interval standard deviation or in the mean respiration amplitude during seizure was observed. These results raise the possibility of using ECG and respiration based methods instead of existing electrcoenceplogram (EEG) based methods, or in concert with EEG-based neonatal seizure detection methods to improve on previously reported seizure detection methods.

Study of the optimum level of electrode placement for the evaluation of absolute lung resistivity with the Mk3.5 EIT system

Inter-subject variability has caused the majority of previous electrical impedance tomography (EIT) techniques to focus on the derivation of relative or difference measures of in vivo tissue resistivity. Implicit in these techniques is the requirement for a reference or previously defined data set. This study assesses the accuracy and optimum electrode placement strategy for a recently developed method which estimates an absolute value of organ resistivity without recourse to a reference data set. Since this measurement of tissue resistivity is absolute, in Ohm metres, it should be possible to use EIT measurements for the objective diagnosis of lung diseases such as pulmonary oedema and emphysema. However, the stability and reproducibility of the method have not yet been investigated fully. To investigate these problems, this study used a Sheffield Mk3.5 system which was configured to operate with eight measurement electrodes. As a result of this study, the absolute resistivity measurement was found to be insensitive to the electrode level between 4 and 5 cm above the xiphoid process. The level of the electrode plane was varied between 2 cm and 7 cm above the xiphoid process. Absolute lung resistivity in 18 normal subjects (age 22.6 +/- 4.9, height 169.1 +/- 5.7 cm, weight 60.6 +/- 4.5 kg, body mass index 21.2 +/- 1.6: mean +/- standard deviation) was measured during both normal and deep breathing for 1 min. Three sets of measurements were made over a period of several days on each of nine of the normal male subjects. No significant differences in absolute lung resistivity were found, either during normal tidal breathing between the electrode levels of 4 and 5 cm (9.3 +/- 2.4 Omega m, 9.6 +/- 1.9 Omega m at 4 and 5 cm, respectively: mean +/- standard deviation) or during deep breathing between the electrode levels of 4 and 5 cm (10.9 +/- 2.9 Omega m and 11.1 +/- 2.3 Omega m, respectively: mean +/- standard deviation). However, the differences in absolute lung resistivity between normal and deep tidal breathing at the same electrode level are significant. No significant difference was found in the coefficient of variation between the electrode levels of 4 and 5 cm (9.5 +/- 3.6%, 8.5 +/- 3.2% at 4 and 5 cm, respectively: mean +/- standard deviation in individual subjects). Therefore, the electrode levels of 4 and 5 cm above the xiphoid process showed reasonable reliability in the measurement of absolute lung resistivity both among individuals and over time.

Lung function tests in neonates and infants with chronic lung disease: global and regional ventilation inhomogeneity

This review considers measurement of global and regional ventilation inhomogeneity (VI) in infants and young children with acute neonatal respiratory disorders and chronic lung disease of infancy (CLDI). We focus primarily on multiple-breath inert gas washout (MBW) and electrical impedance tomography (EIT). The literature is critically reviewed and the relevant methods, equipment, and studies are summarized, including the limitations and strengths of individual techniques, together with the availability and appropriateness of any reference data. There has been a recent resurgence of interest in using MBW to monitor lung function within individuals and between different groups. In the mechanically ventilated, sedated, and paralyzed patient, VI indices can identify serial changes occurring following exogenous surfactant. Similarly, global VI indices appear to be increased in infants with CLDI and to differentiate between infants without lung disease and those with mild, moderate, and severe lung disease following preterm birth. While EIT is a relatively new technique, recent studies suggest that it is feasible in newborn infants, and can quantitatively identify changes in regional lung ventilation following alterations to ventilator settings, positive end expiratory pressure (PEEP), and administration of treatments such as surfactant. As such, EIT represents one of the more exciting prospects for continuous bedside pulmonary monitoring. For both techniques, there is an urgent need to establish guidelines regarding data collection, analysis, and interpretation in infants both with and without CLDI.

EIT images of ventilation: what contributes to the resistivity changes?

One promising application of electrical impedance tomography (EIT) is the monitoring of pulmonary ventilation and edema. Using three-dimensional (3D) finite difference human models as virtual phantoms, the factors that contribute to the observed lung resistivity changes in the EIT images were investigated. The results showed that the factors included not only tissue resistivity or vessel volume changes, but also chest expansion and tissue/organ movement. The chest expansion introduced artifacts in the center of the EIT images, ranging from -2% to 31% of the image magnitude. With the increase of simulated chest expansion, the percentage contribution of chest expansion relative to lung resistivity change in the EIT image remained relatively constant. The averaged resistivity changes in the lung regions caused by chest expansion ranged from 0.65% to 18.31%. Tissue/organ movement resulted in an increased resistivity in the lung region and in the center anterior region of EIT images. The increased resistivity with inspiration observed in the heart region was caused mainly by a drop in the heart position, which reduced the heart area at the electrode level and was replaced by the lung tissue with higher resistivity. This study indicates that for the analysis of EIT, data errors caused by chest expansion and tissue/organ movement need to be considered.

Assessment of the unilateral pulmonary function by means of electrical impedance tomography using a reduced electrode set

The usefulness of electrical impedance tomography (EIT) to assess ventilation-related phenomena in the thorax has already been demonstrated, especially in controlled environments. We focus on our developments in the assessment of the unilateral pulmonary function (UPF) in real clinical environments. The impact of the reduction of the number of electrodes used is analysed theoretically and experimentally with different approaches. Sixteen-electrode EIT measurements were performed on a group of lung cancer patients (19 M, 2 F, ages 25-77 years). Results are compared with those obtained from ventilation scintigraphy. Eight-electrode measurements were synthesized from the 16-electrode ones. The Bland and Altman analysis indicates an agreement of about +/- 1 percent points in the estimation of UPF. On five of these patients real 8-electrode measurements were performed, obtaining differences from 0.2 percent to 6 percent points. It is concluded that reducing the number of electrodes does not adversely affect the assessment of UPF, but there is a reproducibility issue affecting all the techniques which needs further study.

Monitoring water content of rat lung tissuein vivo using microwave reflectometry

Measurement of lung water is an important diagnostic means of assessing pulmonary oedema. Water content affects the dielectric spectrum at microwave frequencies, but quantification is still a problem. A new lung tissue model is presented that allows the calculation of water content from dielectric permittivity. The dielectric permittivity of lung tissue was measured by microwave reflectometry using a non-invasive surface probe. During perfusion of rat lungs (n = 22) with blood, injury was induced by interruption of the blood supply for a duration between 0 (control) and 2 h. Water content was assessed from dielectric permittivity using a new mixture formula and was also determined by drying and weighing. The mixture formula allows for the dielectric polarisation of water, dry matter and air in the tissue. A linear correlation was found between total water content determined from dielectric permittivity and that from drying and weighing (y= 1.001x, R2 = 0.8). Lung injury showed an increase in total water content from 80.9 +/- 1.2% (control) to 84.1 +/- 0.9% (p < 0.01). The analysis of dielectric permittivity data at microwave frequencies with the new tissue model is sensitive enough to detect water accumulation produced by lung injury and it can be used to monitor total water content without tissue destruction.

Neonatal lungs: maturational changes in lung resistivity spectra

The electrical resistivity of lung tissue can be related to the structure and composition of the tissue and also to the air content. Electrical impedance tomographic measurements have been used on 155 normal children over the first three years of life and 25 pre-term infants, to determine the absolute resistivity of lung tissue as a function of frequency. The results show consistent changes with increasing age in both lung tissue resistivity (5.8 ohm m at birth to 20.9 ohm m at 3 years of age) and in the changes of resistivity with frequency (Cole parameter ratio R/S=0.41 at birth and 0.84 at 3 years of age). Comparison with a lung model showed that the measurements are consistent with maturational changes in the number and size of alveoli, the extracapillary blood volume and the size of the extracapillary vessels. However, the results show that the process of maturation is not complete at the age of three years.